APPLICATION FOR ADJUSTMENT OF CLAIM State Form 29109 (R5 / 6-05) FOR STATE USE ONLY Application number INDIANA WORKERS COMPENSATION BOARD 402 W. Washington St., Rm. W196 Indianapolis, IN 46204-2753 INSTRUCTIONS: Please TYPE or PRINT. File ORIGINAL and 4 COPIES. Name of plaintiff / employee Address (number and street) City, state, ZIP code Telephone number ( ) Social Security number * * The request for your Social Security number is VOLUNTARY and you will not be penalized for refusing to supply it. Name of defendant / employer Address (number and street) vs. City, state, ZIP code Telephone number ( ) Employers Workers Compensation insurance company (if known) The undersigned petitioner respectfully requests a hearing before a member of the Board for the following reasons. (please check one) Workers Compensation Claim Occupational Disease Claim Change of Condition ATTENTION: ONLY ONE INJURY DATE PER FORM Date of injury / last exposure / death Date employer notified of illness / injury / death If not within 30 days explain County of incident Actual location of incident (number and street, city, state, ZIP code) Average weekly earning of the employee at the time of illness / injury / death $ Briefly describe how the accident / exposure occurred. If an employee has died as a result of the injury / exposure, complete this section for all persons surviving as all and only dependents. (attach extra information on depenedents if needed) NAME AGE RELATIONSHIP WHOLLY OR PARTIALLY DEPENDENT ADDRESS Comments or additional information that you feel is pertinent to this claim. Name of attorney Address (number and street, city, state, ZIP code) Telephone number Attorney number Signature of petitioner Date signed (month, day, year) SIGN HERE American LegalNet, Inc. www.USCourtForms.com ( )